Trauma kapitis

Prof.DR.Dr.Hasan Sjahrir SpS(K)

Departemen Neurologi FK USU

definisi

Trauma kapitis : adalah trauma mekanik terhadap kepala baik secara langsung ataupun tidak langsung yang menyebabkan gangguan fungsi neurologis yaitu gangguan fisik, kognitif, fungsi psikososial baik temporer maupun permanen.

Sinonim: cedera kepala= head injury =trauma kranioserebral=traumatic brain injury 75% KLL

epidemiology

Incidence head trauma

350

per 100.000 in Europe, 200 per 100.000 in North America, US hospitalization rates due to traumatic brain injury (TBI) are on the rise,

85% mild head injury, 15% moderate - severe Head injury Severe head injury intracranial haemorrhagic lesion 10-27% Less than 2% require neurosurgery

1.Baandrup L & Jensen R. Cephalalgia 2005; 25:132138. 2.National Institute of Health Traumatic Coma Data Bank 3.Ropper AH, Gorson KC. N Engl J Med 2007;356:166-72 4.Thomas & Kegler. Morb Mortal Wkly Rep. 2007;56:167-170

Berat ringan cedera otak tgt:

Besar & kekuatan benturan Arah & tempat Posisi/keadaan kepala

Lesi yang terjadi:

Lesi bentur(coup) Lesi media/antara Lesi kontra(counter coup)

Akibat lesi bentur thd otak

Blockade ARAS Retensi cairan & elektrolit TIK meninggi Perdarahan Kerusakan otak primer Kerusakan otak sekunder

Pemeriksaan neurologis

Monitor batang otak

Besar & reaksi pupil, refleks kornea Dolls eye phenomen Cheyne stokes lesi hemisfer Centr neuro hyperventilation lesi mesensefalon-pons Apneustic breathing : lesi pons Ataxic breathing lesi medula oblongata

Monitor pernafasan

Monitor fungsi motorik Brills hematon, likuorrhea,battles sign Funduskopi Radiologi EEG

TBI (Traumatic Brain Injury)

Closed head injury

Primary injury

Concussion Contusion Hematoma epidural, subdural, intraventricular, subarachnoid

Secondary

Hypotension, hypoxia, acidosis, edema, ischaemia or other subsequent factors that can secondary damage brain tissue

Penetrating head injury

Eye Opening Score 4 3 2 1 Spontaneously To verbal command To pain No response Best Motor Response Score 6 5 4 3 2 1 Obeys command Localizes pain Flexion withdrawal Flexion abnormal (decorticate) Extension (decerebrate) No response Best Verbal Response Score 5 4 3 2 1 >5 Years Oriented and converses Disoriented and converses Inappropriate words; cries Incomprehensible sounds No response 2-5 Years Appropriate words Inappropriate words Screams Grunts No response 0-2 Years Cries appropriately Cries Inappropriate crying/screaming Grunts No response Localizes pain Flexion withdrawal Flexion abnormal (decorticate) Extension (decerebrate) No response 1 Year 0-1 Year 1 Year 0-1 Year Spontaneously To shout To pain No response

Normal Skor pada anak: < 6 bulan : 12 6-12 bulan : 12 1-2 thn : 13 2-5 thn : 14 > 5 thn : 14

Normal skor Dewasa 4+5+6=15

klasifikasi

TK non Operatif Komosio cerebri Kontusio c Impresio fraktur non neurologik (< 1 cm) Fraktur basis kranii Fraktur kranii tertutup TK operatif Hematoma intrakranial > 75 cc

Epidural, subdural, intraserebral/serebellar

Fraktur kranii terbuka ( + laserasio) Impresi frk dengan kelainan neurologik (> 1 cm) Likuorrhoe yang tidak berhenti

Klasifikasi trauma kapitis berdasarkan WHO: (......ICD)

Patologi:

Lokasi lesi

Komosio serebri Kontusio serebri Laserasio serebri

Lesi diffus Lesi kerusakan vaskuler otak Lesi fokal

Kontusio dan laserasi serebri Hematoma intrakranial

hematoma ekstradural(hematoma epidural) hematoma subdural hematoma intraparenkhimal hematoma subarakhnoid hematoma intraserebral hematoma intraserebellar

Klasifikasi berdasarkan SKG di triase

Kategori SKG Gambaran Klinik CT Sken otak

minimal
Ringan

15

Pingsan (-),defisit neurologi(-) 13- Pingsan < 10 men, 15 defisit neurologik (-)
9-12 Pingsan >10 men s/d 6 jam Defisit neurologik (+) 3-8 Pingsan>6 jam, defisit neurologik (+)

Normal
Normal

Sedang

Abnormal

Berat

abnormal

Catatan: Jika abnormalitas CT Sken berupa perdarahan intrakranial, penderita dimasukkan klasifikasi trauma kapitis berat

Diagnostik :

Trauma kapitis ringan(TKR) Mild Head injury:

SKG 13-15, CT Sken normal, pingsan < 30 menit, tidak ada lesi operatif, rawat Rumah sakit < 48 jam, amnesia pasca trauma (APT) < 1 jam SKG 9-12 dan dirawat > 48 jam, atau SKG > 12 akan tetapi ada lesi operatif intrakranial atau abnormal CT Sken, pingsan >30 menit- 24 jam, APT 1-24 jam SKG < 9 yang menetap dalam 48 jam sesudah trauma, pingsan > 24 jam, APT > 7 hari.

TKS=Moderate Head Injury

TKB=Severe Head injury:

Komosio serebri (80%)

Definisi: disfungsi neuron otak sementara, makroskopis normal

Gejala:
Pening/sakit kepala Tidak sadar < 30 menit Amnesia retrograde (AR) ,Amnesia anterograde (PTA) Mual muntah

Pasien harus opname minimal 48 jam

Kontusio serebri (15-19%)

Definisi: perdarahan interstitiil parenchym otak,tanpa putusnya kontinuinitas jaringan. =/= laserasio serebri Gejala gangguan neurologi fokal (+/-) Gejala

Tidak sadar > 30 menit FASE I :Fase shock FASE II : FAse hiperaktif sentral FASE III : serebral oedem FASE IV: fase regenerasi/rekovalesens

Kontusi serebri pada anak2

Fase latent Fase akut serebral (II) Fase regenerasi

Epidural hematom

Def : antara tabula interna- duramater Lucid interval pendek Jarang pada anak2 Hematom massif:

Arteri meningea media Sinus venosus Dx: Brain ct scan

X foto polos

Gejala epidural H

Lucid interval (+) pendek : yaitu periode sadar diantara 2 fase penurunan kesadaran Kesadaran makin menurun Hemiparese terlambat Pupil anisokor Babinsky (+) Fraktur menyilang di temporal Kejang bradikardi

Gejala EDH fossa posterior

Lucid interval tidak jelas Fraktur krainii oksipital Kehilangan kesadaran cepat Gangguan serebellum, batang otak, pernafasan Pupil isokor Prognosa jelek

Subdural hematom

Def : duramater arakhnoid =/= hygroma subdural Hematom:

Bridging vein robek Kausa: Tr.Kapitis, keheksi, ggan darah

Lokasi frontal ,parietal, temporal Gejala/klasifikasi

Akut : Lucid interval 0-5 hari Subakut : 5-15 hari Kronik : 15 hari - tahun

Intraserebral hematom

Dwf: pecahnya arteri intraserebral/serebellar Mono- multiple

Fraktur basis kranii

Anterior Media Posterior Diagnosa tgt gejala ,sebab x foto hanya 50%(+)

X foto

X foto tengkorak 30% , fraktur (+) 3-5% kelainan intrakranial kepentingan:

Kematian 80% fraktur (+) Medikolegal kepentingan pengawasan klinik

Penanggulangan trauma kapitis akut

Atasi shock Air way Evaluasi kesadaran Amati jejas kepala & tubuh Awas fraktur servikalis Klinik neurologi & X ray Atasi oedema serebri Keseimbangan cairan & elektrolit, kalori Monitor tek intra kranial Pengobatan konservatif Refer bedah satraf atas dasar indikasi

Oedema serebri
Def: peninggian cairan intra/ekstra sel otak o.k. proses lokal atau umum Jenis
Vasogenik Sitotoksik Osmotik hidrostatik

VASO
pato lokalisasi BBB subs alba

SITO
sod pump alb+grisea

OSMO
osmotik alb+grisea

HIDRO
gga LCS alba

permeable
histologis unsur

meninggi
ekstrasel plasma

normal
intra plasma

normal
eks+intra air

normal
ekstrasel air+Na

 Vasogenik : Tr kapitis, stroke, meningitis, ensefalitis, SOL, hipertensi malignan, konvulsi Sitotoksik: asfiksia, cardiac arrent, zat toksik Osmotik: water intoxication, hemodialisis Hidrostatik: hidrosefalus

Obat anti oedema

Hipertonik sol: manitol ,gliserol Kortikosteroid Barbiturat Hipothermi Hiperventilasi artifisiil

INDIKASI OPERASI PENDERITA TRAUMA KRANIOSEREBRAL EDH (epidural hematoma) ;

> 40 cc dengan midline shifting pada daerah temporal / frontal / parietal dengan fungsi batang otak masih baik. > 30 cc pada daerah fossa posterior dengan tanda-tanda penekanan batang otak atau hidrosefalus dengan fungsi batang otak masih baik. EDH progresif. EDH tipis dengan penurunan kesadaran bukan indikasi operasi.

SDH (subdural hematoma)

SDH luas (> 40 cc / > 5 mm) dengan GCS > 6, fungsi batang otak masih baik. SDH tipis dengan penurunan kesadaran bukan indikasi operasi. SDH dengan edema serebri / kontusio serebri disertai midline shifting dengan fungsi batang otak masih baik.

INDIKASI OPERASI PENDERITA TRAUMA KRANIOSEREBRAL

Indikasi operasi ICH pasca trauma sama seperti stroke hemoragis. Fraktur impresi melebihi 1 (satu) diploe. Fraktur kranii dengan laserasi serebri. Fraktur kranii terbuka (pencegahan infeksi intra-kranial). Edema serebri berat (disertai tanda peningkatan TIK) ------ pertimbangan dekompresi.

Low-level responsive states

Coma acute brain functioning failurebrain stem and/or cerebral hemisphere lesion Persistent vegetative state ( coma vigile)eye are open(respons to sounds) but not respond to any kind of stimulation(total lack of cognitive function)=apallic state absence of neocortical functions Locked-in syndrome (LIS)quadriplegia, lateral gaze palsy, paralytic mutism, fully conscious and aware of environment ventral of pons lesion Minimally responsive state Akinetic mutismlack of movement (not completely paralyzed) & speech, can eye open lesion frontal basal Jose al. Brain Injury Treatment.2006 andLeon-Carrion posterior et region of mid brain

PARAMETER OF POOR PROGNOSIS IN PATIENTS IN PROLONGED STATE OF COMA

Brain Injury Treatment, 2006

CHARACTERISTIC

with recovery

without recovery

significance

SIGN OF HYPOTHALAMIC Fever perspiration diffuse MOTOR REACTIVITY No answer Decerebrate Decorticate 8% 49% 73% 92% 51% 30% 30% 16% 57% 54% p<0.03 p<0.005

5 factors that correlated with poor outcome

Age older than 60 years Initial GCS score of less than 5 Fixed dilated pupil Prlonged hypotension or hypoxia Presence of surgical intracranial mass lesion
The traumatic coma data bank

The temporal lobes & frontal lobe are commonly injury

Physiologic disruption of hippocampal function

Disturbing memory storage and retrieval

Post Traumatic Amnesia (PTA) (Retrograde and Anterograde Amnesia)

Duration of PTA
the duration of PTA is related to the degree of residual memory deficit , disability and a higher probability of personality change after TBI

Amnesia from Head Injury

British boxer Nigel Benn lands a punch to the head of American boxer Gerald McClellan during a 1995 fight in London. McClellan suffered severe brain damage in the fight that left him blind and that impaired his ability to form new memories and access long-term memories.

Neuro behavioural problems of TBI

Behavioral and emotional problems cognitive impairmentcontribute more to persistent disability than do physical impairment sequelae in 72% of patients surviving head trauma
Kewman DG, Siegerman C,et al,1985

Brooks N,McKinlay W et al.Brain Inj 1987

Neurobehavioural symptoms post TBI

Poor sleep patern Poor drive and motivation Tiredness Socially withdrawn Headache Impulsive Aggressive Anxiety depression

Neurobehavioural symptoms post TBI

Aggressive behaviour is a frequent sequela of TBI A 70% incidence of postraumatic irritability of which 20% was defined as violent behaviour patient who display aggresion postraumatic exhibit significantly more verbal & executive deficits.
Wood RL,Liossi C. J.Neuropsychiatry Clin Neurosci 2006;18:333-341

The locus of TBI is the key predicator of behavioral problems

Frontal lobe : changes in emotional control, initiation, motivation, inhibition Temporal lobe:agression, memory loss, aphasia Limbic system:distorts emotion, difficulty perception/organization Parietal lobe : apraxia, neglect, agnosia Occipital lobe : acalculia, agnosia, alexia

The end